- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.46 / $10.58 / $10.58
| Facility | | $8.46 | $10.58 | $10.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.58 / $10.58 / $20.00
| Professional | | $10.58 | $10.58 | $20.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.72 / $171.36 / $183.69
| Professional | | $144.72 | $171.36 | $183.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.28 / $246.33 / $449.55
| Facility | | $93.28 | $246.33 | $449.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.44 / $255.54 / $300.00
| Professional | | $204.44 | $255.54 | $300.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.24 / $215.25 / $390.00
| Professional | | $40.24 | $215.25 | $390.00 |